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. 2020 Feb;35(2):161-169.
doi: 10.1177/0885066617732747. Epub 2017 Sep 22.

High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction

Leonie J M Vergouw  1   2 , Mohamud Egal  1 , Bas Bergmans  1 , Diederik W J Dippel  2 , Hester F Lingsma  3 , Mervyn D I Vergouwen  4 , Peter W A Willems  5 , Annemarie W Oldenbeuving  6 , Jan Bakker  1 , Mathieu van der Jagt  1
Affiliations

High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction

Leonie J M Vergouw et al. J Intensive Care Med. 2020 Feb.

Abstract

Background: Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT).

Methods: We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2).

Results: Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable.

Conclusion: High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.

Keywords: aneurysmal subarachnoid hemorrhage; delayed cerebral ischemia; fluid management; hypervolemia; transpulmonary thermodilution.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Schematic representation of the study design. TPT, transpulmonary thermodilution; aSAH, acute subarachnoid hemorrhage; ICU, intensive care unit; CVP, central venous pressure; CI, cardiac index; SVI, stroke volume index; EVLWI, extravascular lung water index; GEDVI, global end-diastolic volume index.
Figure 2.
Figure 2.
Daily fluid parameters in cohort 1. Data are represented as mean with 95% CI as 1-sided error bar. Differences between patients with and without DCI are indicated in figures: *P < .01. ICU, intensive care unit; DCI, delayed cerebral ischemia; CI, confidence interval.
Figure 3.
Figure 3.
Daily fluid parameters and associated course of GCS in cohort 2. Data are represented as mean with standard error as 1-sided error bar and median with interquartile range for GCS. The TPT day 3 is used as the reference value (R) for the comparisons. + P < .05; *P < .01; **P < .001. TPT, transpulmonary thermodilution; GCS, Glasgow coma scale.
See this image and copyright information in PMC

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